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          <h1 class="post-title" itemprop="name headline">020.2019新锐读会 课程笔记《粘接牙科学的基本原理》03</h1>
        

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        <p>第三阶段：牙体的粘接<br>第三章：牙体与粘接系统<br>第一节：三步粘接体系的粘接原理<br>1.市场相关产品：OptiBond FL (Kerr)<br>酸蚀剂+底漆+粘接剂<br>2.传统三步粘接体系各组分与牙体的粘接原理<br>第一步：酸蚀<br>概述：<br>a.浓度32-37%pH值-0.1-0.1，需要冲洗。<br>32%-流动性好，釉质本质通用<br>35%（HV 高粘度高稳定性）-选择性酸蚀<br>37%-正畸使用<br>b.凝胶类型<br>全凝胶常用氧化硅，价廉，使用麻烦，冲洗后有氧化硅残留。<br>半凝胶用有机多聚物作为增稠剂，贵，使用便利。<br>半凝胶为趋势。<br>c.是否含抑菌剂？<br>酸蚀后牙本质脱矿，涂底漆和粘接剂的深度与酸蚀深度未必一致。酸能激活牙本质中的基质金属蛋白酶（MMP），有降解未被底漆和粘接剂包裹的胶原纤维的能力。影响粘接强度。用含氯的消毒剂能抑制该酶的活性。（洗必泰等）在酸蚀剂中加入含氯成分（BAC）也行，减少洗必泰处理的步骤。<br>d.与釉质作用机制<br>有釉柱釉质层15-30s<br>釉柱中心脱矿：蜂窝状<br>釉柱周围脱矿：鱼鳞状<br>混合的情况：混合状。<br>无釉柱釉质层30s<br>酸蚀时先酸蚀釉质表层，再酸蚀切割过的釉质。<br>e.与本质作用机制<br>酸蚀10-15s<br>玷污层-管间牙本质脱矿，胶原暴露-管周牙本质脱矿，小管变粗。<br>酸蚀后牙本质保持湿润状态下，保证胶原纤维蓬松。<br>第二步：底漆<br>目的：是可以和湿性牙本质表面发生反应加固酸蚀后暴露的胶原纤维层，以建立牙本质与粘接树脂的强效连接。<br>概述<br>也叫偶联剂，升高牙本质表面自由能，使牙本质具有亲水性，帮助粘接剂渗入。<br>a.传统底漆构成<br>双性树脂单体（如HEMA, 二甲基丙烯酸甘油酯，4-META，Gluma（Heraeus kulzer））<br>溶剂为丙酮或乙醇，将胶原纤维网中的水带走。<br>b.底漆中各成分的作用<br>1）溶剂：载体作用，将水载出，双溶性树脂载入。<br>2）双性树脂：占位与衔接作用。<br>c.底漆中的溶剂类型及界面要求<br>乙醇型——微湿界面<br>丙酮型——明湿界面、挥发快，挥发强，允许操作时间短。牙面稍干燥胶原纤维会塌陷。<br>酸蚀冲洗后一般用强吸来吸2-3s。<br>胶原纤维复原能力——乙醇&gt;丙酮。目前多为乙醇。<br>d.底漆的涂抹方法、时间、吹干标准<br>微用力搅动涂布<br>两次涂布每次10-15s共20-30s<br>吹到表面发亮无可动膜。<br>第三步：粘结树脂<br>概述<br>a.常规成分组成及意义<br>疏水树脂单体(Bis-GMA与TEGDMA)：建立固化后疏水特性<br>亲水树脂单体如HEMA少量（或有或无)：与底漆连接<br>光敏引发剂：光固化<br>b.粘接树脂作用<br>连接底漆和后续的复合树脂材料<br>覆盖底漆的亲水层<br>固化后在底漆与复合材料间创建疏水屏障<br>封闭牙本质小管<br>c.粘接树脂的稳定性<br>粘接树脂的水解与其中的亲水成分比例有关<br>d.粘接树脂的改良<br>减少或不含HEMA（HEMA-free）<br>第二节 两步法粘接体系的粘接原理<br>第五代：酸、底漆+粘接剂。<br>第六代：酸+底漆、粘接剂。<br>第五代<br>1.市场相关产品<br>Single Bond<br>One-STEP<br>OptiBond<br>2.粘接原理（同三步全酸类似）<br>底漆与粘接树脂合二为一，底漆中有溶剂，有双性树脂，有亲水性。不能保持自己独立的疏水系统。<br>3.临床改良（外部改良）<br>固化后再涂一层疏水树脂。<br>成膜厚度过厚，不宜用于间接修复。<br>临床改良（内部改良）<br>增加高度交联体，固化前亲水，固化后疏水。<br>Bisco All-Bond3<br>4.临床标准使用流程<br>a.直接修复流程<br>step1：先酸蚀牙釉质15s<br>step2：再酸蚀牙本质10-15s<br>step3：彻底清洗磷酸<br>step4：强吸吸净多余水分<br>step5：保证牙本质可见湿度<br>step6：1:1混合All-Bond 3(A+B)5s<br>step7：毛刷反复涂布10-15s重复一次。<br>step8：温和的干燥10s（标准：无可见材料流动表面有光泽）<br>step9：光固化20-40s<br>step10：涂布一薄层All-Bond3 Resin或流体树脂（小于等于0.5mm）（可以使用气枪吹匀）<br>step11：光固化20s<br>step12：分层堆塑树脂。<br>b.间接修复流程（略）<br>c.桩粘接流程<br>step1：髓腔喷砂制备桩道（氧化铝髓腔喷砂）<br>step2：清洗桩道<br>step3：根管刷清洗<br>step4：超声荡洗<br>step5：纸捻吸干<br>step6：选桩试桩<br>step7：32%磷酸酸蚀桩道<br>step8：桩道冲洗<br>step9：超声荡洗桩道（彻底清除磷酸否则影响粘接）<br>step10：强吸吸净<br>step11：纸捻去除水份（纸尖尖端不弯不湿）<br>step12：1:1混合All-Bond3(A+B)<br>step13：反复涂布根管壁10-15s，再重复一遍。<br>step14：纸尖吸去多余粘接剂<br>step15：固化40s<br>step16：距离5cm压力2bar氧化铝27-50μm转动喷砂10s超声荡洗2-5min干燥，涂布粘接剂，吹薄。<br>step17：光固化20s<br>step18：准备双固化（自固化能力强）的复合材料<br>step19：先打出1cm左右，弃去不用，注入根管，后退式。<br>step20：插入纤维桩<br>step21：就位固定后固化<br><strong>个人总结：四代和五代粘接系统的介绍。四代，酸蚀剂、底漆、粘接剂三组分。酸蚀剂有32%，35%，37%三种，32%牙釉质牙本质通用，35%用于牙釉质，37%用于正畸。有全凝胶和半凝胶的区别，半凝胶为趋势。酸蚀剂能激活牙本质中的MMP，影响粘接。使用含氯的消毒剂或含有BAC成分的酸蚀剂能抑制MMP。底漆是偶联剂，能将胶原纤维中的水分置换为双性树脂，避免胶原纤维网塌陷。底漆含有溶剂，主要有乙醇和丙酮，乙醇的较好。粘接树脂有含HEMA和HEMA-free的。五代，底漆与粘接剂合二为一，问题是表面有亲水性。对其的改良是增加一个疏水成分，但会增加成膜厚度，因此不宜用于间接修复。</strong></p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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